flash point. it's a potential political flash point. at the time people said, no, mosul is different than fallujah because for a long time fallujah was a problem for iraq. whether during the saddam hussein regime or when the americans were there. they resisted any political order in baghdad. they didn't want to be dominated and so on and so forth. but mosul is a problem for many reasons. one is that -- i think we have reached a point in the fight against isis in both iraq and syria and we're going to get into syria in a little bit. where politics matters more than the military challenge against isis. and mosul is a perfect example because there are so many -- so many stakeholders are involved in mosul and many people want a piece of the pie in mosul.

unlike fallujah. fallujah was a military challenge. a political challenge but more of a military challenge then. it was up to the iraqi government and the americans to sort out what's the best formula in fallujah. but in mosul it's not up to the iraqi government or up to the americans to sort out what's best there. there are the kurds there and different kurds involved in there. the krg, the regional government doesn't have the support of everyone inside kurdistan to back certain political agendas in mosul. for example, you know, you're an expert in this. the turkish involvement inside iraq is a perfect -- is a good example because while president supported it, others opposed it. and you have also that pkk is a

major concern for turkey near talafar. it's a problematic area, it will be a big flash point. west of -- west of -- northwest of mosul. it's a turk dominated area. turkey said that the militia should should not be there, but the turks are more problem -- more concerned about the pkk rise in sinjar near talafar. so the americans see some of the fault lines for now and things are going very well for now. but i think isis will try to destroy the current strategy which is actually very promising by trying to fight in mosul for say four months.

if it does that i think many of these alliances will collapse. there are already signs of tension between different factions fighting outside mosul. i think these tensions will increase. will intensify. and we will see in a few months that the situation on the ground is going to be completely different. i think issue will be able to hold on to the city for quite a while. i think there was -- there has been a lot of wishful thinking about the city collapsing somehow the -- that isis members will choose to go to raqqah. that's why we have confused reporting coming from out of washington. some say fighters coming from raqqah into mosul and some say fighters are actually moving from mosul outside. so you have ethnic, sectarian, geopolitical and i think this will emerge and become even more intense in the coming weeks and months. >> pick up on that.

>> well just to agree that the longer the battle for mosul goes the longer the broader the operation becomes with operations in talafar and the more defuse the operation will become as well, which leaves room for coalition members to become delinked. the road from mosul to talafar to sinjar to syria is perhaps more important for members of the coalition who have dispirit interests in those places than it is for isis tactically. the desert beneath that road to the south and southwest of mosul is traversable. we are entering the winter season which makes it slightly less so, but the winter season makes the biggest constraint upon isis' movement in there is the visibility as well.

so there are ways for isis to escape and vet elsewhere. but i would also say that isis has been preparing for the battle of mosul for a long time and that the preparations probably already occurred so we'll see other responses from isis elsewhere in iraq where it has established positions already. if i may add one more point. perhaps just to mention it now and we can discuss it more perhaps during question and answer. there are other threats that stem from the grievances of sunni arabs in iraq that could also produce spoilers to the coalition. if the grievances are not addressed which they're not likely to be addressed quickly. there are other elements who are seeking to be champions of iraq sunni population. not only the neo ba'athist organization that was trying to capture the sunni movement

before isis came in to control the cities in 2014, but also al qaeda. al qaeda and syria, the affiliate -- which has reflagged itself is already conducting outreach to tribes in anbar. al qaeda is going to make a play to become a silent vanguard of the sunni insurgency in iraq. if the grievances are noed addressed the vulnerability will remain open and in the vacuum of control by isis you could see mobilization of sunnis under a different flag. so to put that on the list of challenges that need to make sure we're thinking about and facing. >> anything to add perhaps maybe the road -- does it fit into as you mentioned in your intro about both the economic -- important to the transnational movement of the group and efforts to the coalition to attack that at the moment?

are they putting pressure on it and do you see that as linked into the broader struggle now the current focus on -- >> you're talking about the iraq/syria link. >> the link. >> so this is actually very important to think about movement being possible through the desert. because we're going to see movement back and forth. let me credit the citations. i think as i talk, you should just assume that i'm probably citing somewhere hassan and jessica and aaron without saying it. we might end up doing a circular citation at some point. but i want to cite very good work by iraqi oil report now which is showing islamic state fighters leaving the city, going towards syria. so stopping those routes or being able to track those fighters is going to be important. the islamic state is very cognizant of issues of air cover. as far back as 2007, 2008, we

have a strategy document from them where they talk specifically of oh, what to do to -- of how effective coalition air forces were of how they were able to move soldiers and what the group should do to stop air forces from seeing their operations. so they are -- whatever they do, they're quite cognizant of that. so those routes are historically important moving people. the real first strong evidence we had of how predecessor groups -- fighters were known as the sinjar documents, a cache of documents describing a -- detailing the borders and fighter flows in and out. the other issue about this area, i don't know how much

significant importance it has. there was a test and resurgence against isis and this is where some of the current islamic state leaders come from. so, you know it's going to be a bit of a flash point. and as hassan said, you know, and jessica said, shiia pmus coming in. very diverse. i don't want to characterize them as all one way or the other. it's a mistake to group the pmus as one -- as one mass. but how they handle civilians, how much of a fight islamic state decides to put up is going to be very important. >> just to pick up on some of my own work, my work and focus is mainly on the islamic state's network in turkey. and both talapa and sinjar, we conceptualize it here, most people do, as the turkish problem with isis emerged late

because it was the primary transit route for foreign fighters that came into the current conflict and by that beginning in say 2014. if you look at historically, obviously syria was the main entry point into iraq. but you had to get to syria. so one of the ways through was exactly the routes that are now being leveraged. although less so which is to move through southeastern turkey. to smuggle yourself across the border and the go across. so this brings us back into how, you know, isis should not be thought of as simply -- both hassan and jessica's work as well, as a sort of the boots on the ground military force that can be beaten back, but has the tent acals of bureaucracy that extends out into the region. it's a good segue, not just a battle in mosul, but you know that road stops some place. in this town, in washington. there's a lot of talk now of

putting simultaneous pressure on the islamic state. so we have the pressure being put on mosul and putting pressure on them in raqqah. but a lot of -- i would say whereas the coalition in iraq is stitched together and i would say it's stitched together pretty well, the syrian case provides a lot -- for now, syrian case provides a lot of complications because the primary force poised to go are something we call here the syrian democratic forces. let's say the majority of which are the -- they call themselves the democratic union party. the pyd that have a militia, who are kurds and are poised to go -- well, they are suggestions they could go and this raises those same ethnic tensions that isis feeds on. intrakurdish, intraarab tensions at this other flash point now of raqqah. >> i mean, this is going to be a

big problem in raqqah. for a long time i think it was recognized that isis presence in syria is much shallower than the one in iraq. there's a legacy in iraq. there are alternatives in syria to isis and sunni insurgent groups. that's why i think raqqah is going to be 5 -- that's going to be -- i mean, the challenge in raqqah is different. it's not against -- it's not a military challenge. just like i said earlier the challenge for -- and the fight against isis today is really concentrated in the northern parts of iraq and syria. raqqah, i feel this time and again here in washington, how -- how much -- not hated but feared and suspected their suspicion about the kurdish force inside

syria. when it comes to the syrian rebels, to the local populations there. this is because the syrian democratic forces and here we're talking really about the ypg, rather than the arab components within the sdf. that they -- there's a perception that these guys are -- they want to dominate in northern syria and they want to cleanse and de-kind of populate the areas to put back some of the kurdish families that were displaced back in the '70s by the ba'ath party in syria. so there's this fear that they have an agenda and this agenda is directly involved in the population in there. there's -- i think washington politicians here underplay that and they say, you know, let's deal with isis. let's expel isis from raqqah and then we will deal with the political mess afterwards. and we promise you that the

kurds will leave raqqah. they won't stay in raqqah. this is kind of the cliche. and i think for a long time i think until recently until probably the past one or two months, there was a debate about really are there alternatives? can we work with someone else other than the sdf? but recently i think because the current administration is running out of time that they're becoming more unequivocal about who's going there. they want the kurds to go there. this is going to be a problem because we know that if raqqah is retaken by the kurds, even if isis is expelled from there and there's good news in that of itself i think the sentiments, the local sentiments is going to be seized by al qaeda and other extremist forces who are local. many of them -- many fighters who are fighting now in aleppo

and even in southern syria who are feared the extremist forces they were driven by isis from raqqah. these guys are going to go back. there's a concern about avoid -- they will exploit. and that void is going to be the kurdish arab tension. i think that's a big selling point for them. and they are already kind of utilizing that to say the kurds have an agenda. separatist agenda. and they have also an ethnic cleansing agenda there. so i think raqqah is a problem in that sense. i don't think there are arab forces on the other hand who are capable of going into raqqah. so there's a dilemma. do you delay raqqah so much that isis will entrench itself there and delay -- kind of go past the momentum in mosul. or you rush into raqqah by sending in the ypg forces there.

>> you want to pick up on that dilemma too. because i think that's important to put your finger on. i think there's recognition that it's problematic ethnically and long earn term politically. but there's an inherent desire to keep up the offensive because isis is -- you have to -- from a political standpoint here and a military standpoint, you want to oust them as quickly as possible so they can't congregate and plan attacks against the west. >> i want to quickly echo two of the points and the first about the kurdish aerodynamic inside of syria, to give an example of how this has played out before, when the sdf in conjunction with our coalition drove isis out of shedadi, between mosul and raqqah, the sunni arab population fled south and into isis held territory. that's how they felt about the

idea of being liberated by a predominantly kurdish force that dynamic is still a vulnerability and a risk when it comes to the raqqah operation. it's one of the reasons that the dilemma exists. on the other side it is not only the concern about the lack of capacity of turkish backed operation forces who want to go to raqqah to head off a kur dish liberation operation, but the fact that al qaeda is part of that coalition of opposition groups. so to have al qaeda linked groups take raqqah from isis is to enable al qaeda. to me, the reason why the dilemma is becoming so complicated and so sharp inside syria is because a lot of our options to deal with isis in the context of so many sectarian and ethnic fault lines and seams that have played out so violently over the course of these last years in syria is the fact that our anti-isis policy

does not address al qaeda. so if it doesn't block al qaeda, it enables al qaeda which leaves us in a dilemma. >> anything to add? >> yeah. i'll take this dilemma and try to double it. so with islamic state it's always a good idea to take territory from them. and it's always a good idea to do it right, however. why is it a good idea to take territory from them? even though much of our focus on their fund-raising is about oil, current estimates coming midyear from the u.s. treasury which is our most credible source at this point are they're getting higher levels of revenue from taxation. and extortion. and this takes place with population centers. so, you know, they have all manner of fines. you would be fined for not having the right beard, you

would be fined for wearing your pants below your ankle. you would be charged for a parking space. all of this diversified ways to raise money. if you have a city like raqqah a 150 to 300,000 people we don't have a current census. all of a sudden, those are people who can pay fines and fees and help the group raise money. so you want to always reduce their territory. the difficulty as my colleague said is who actually does that? and here i'm going to divide this into two stages. one is who does the liberating and then who does the holding? so two stages. now, you know, the kurds -- the ypg forces or the sdf so largely kurds, some arabs, are probably best placed militarily to do

that liberating right now. that's the calculation of the coalition. they are not the best place as we said to do the holding because of little more complicated is i think the syrian kurds have no interest in staying in raqqah. it's not their historic territory. they weren't displaced from there. it's too far south. they do want to hold kurdish territory. they are already deemed an autonomous administration. if they don't want to hold it, be but they are the liberating force, that leads to the next question. what's the bargain? what are they going to demand in turn or what can we, the u.s., force upon them to leave, if we can, push them to leave. part of that bargain is going to have to be agreement with turkey and primarily with turkey has the biggest concern about them. so there are going to be all these issues that enter into raqqah liberation.

>> i'll pick up here and add. you've had this turkish intervention across the border. operation euphrates shield, and it's succeeded in its primary objective, which is to push isis off the border. in doing so, it blocked the foreign fighter entry points into syria any longer. there are really no areas in which somebody wanting to join isis can get into syria any longer. certainly, there are ways they can get in. they can pay smuggling, but it's not anything like it was when i was living there in 2013 and slightly after that. it raises a whole other host of problems. i'm going to double down on the problems. i promise we'll give the audience something hopeful at the end before we turn to questions. it's like another flash point.

isis held but sits 10 to 15 kilometers from regime territory which is south. it's on either side, the kurds hold either side, anywhere from 15 to 20 kilometers depending on day. you have kurdish backed forces above it. they all can converge here. so all of the threads of the disparate war inside of syria can come together with any means of escalation, turkey-syria, turkey-russia, assuming that can be managed. more importantly, on the ethnic cleavages that isis preys upon, you have a race upon kurds and turks more or less for a town that isis is now holding. i'm going to ask an extremely provocative question before we move to the positive and uplifting note of policy

recommendations. and questions, the most important part of the presentation. el bob, i would say, isis is the stabilizing force at the moment. do we have an incentive to try to stave off the interethnic insurgency that would come after isis by focusing on the political challenges of raqqah first? >> it's a tough question. it's one of the areas where from locals were involved in the jihad in iraq, so there are some routes for isis in the area. it's going to be much tougher than elsewhere. we thought it was going to be tough, and it was tough. it caught the kurdish forces, one of the highest casualties after kaboni. al bab will be a whole different level.

there is that different forces on the outskirts, and they want to go in or don't want to because i think some secretly want the regime to go into al bab because that will save the americans a lot of blood and treasure and also save northern american blood, but forces backed by the americans. turkey, there's not evidence to this, but i can imagine the turks would like the region to take al bab because that would be a buffer between the kurds and their different holdings in aleppo and raqqah. nobody has an answer to that. i think the syrian rebels do not have the capacity to go there. if the kurds go there, it's going to cost them a lot of blood and treasure as well. and distract from raqqah. it's going to be a protracted war.

it's a difficult terrain. >> anybody else? >> just the broader point that the dynamics of the syrian war are independent of isis. isis drew strength from that conflict. to me, your question is a microcosm of a bigger question. that is, can you defeat isis while the syrian war is still raging? which does by all means draw in not just neighboring states, but regional states and put them in conflict such that the movement of tactical engagements can stoke regional volatility. it's a great question. i would not wish to call isis a stabilizing force -- >> i said it was provocative. >> but i think it is possible to design operations and campaigns

with it as a necessary condition that the hold force will neither be x or y. it will be something else that will perpetuate a stable moment. now, the hold force that has taken hold from many of the places reclaimed from isis in iraq cannot necessarily met that criterion, so the whole force is perhaps the key element of the campaign such that getting to claim a victory tactically against isis, taking back a small town or a very large city, is going to stick to the tune of isis not having a chance to come back. >> you want to pick up on anything? >> this is great in diagnosing problems, but if you can't treat the problems, what point is it

in having everybody come here and listen to us speak? it's an immense challenge. and we talked about the inherent conflict of being able to push them out of territory to decrease their revenue base, but also to disrupt their plots potentially against the west, which is what we care about most here. so how would you treat these two conflicts? what policy recommendations would you put in place for the next administration whether it be donald trump or hillary clinton? >> iraq and syria? >> iraq and syria. >> easy. i'll start from the segue, the previous one, because i think your phrase stabilizing force makes sense. i don't think syria is ready for the demise of isis yet. i don't think we should talk about the day after yet because there are two things happening here. isis is a threat to the west and the way it operates in syria.

there's no question about that. so that's a consideration. do you keep isis as a governing body in syria or not? and i think that has to be weighed against something else, and i think it's a very important one. if you expel isis today from raqqah and elsewhere, it's going to open a new conflict in syria. many low intensity, but very dangers conflicts in these areas. that's not to say keep isis, but to say that the necessary forces unfortunately washington was not ready to engage and work with are the right forces. these forces are the only forces are if they expel isis and if they're trained well to fill the void, i think this is a phrase that i will keep repeating. fill the void because that's the only way when we talk about isis the day after, filling the void

is going to be the key factor for defeating isis. in syria, you demolish isis. there is going to be a massive vacuum? who is going to fill that? the regime, the kurds, the eric forces. the arab forces were the right forces, not because they're sectarian, not because we hate the kurds. the kurds should be supported in their areas, should be backed, and the turkish should not go after them if they operate in their areas. also recognizing the other kurdish forces that are legitimate actors in the areas. the kurds who are with the opposition who now expel them, not allowed to go to the area by the ypg. i think in that sense, the policy recommendation would be to really double down on preparing the right forces, sunni, arab forces, and i'm not talking in the sectarian sense

but in the demographic sense, local forces who are the people who would be welcome in rocky, would be welcome in eastern aleppo. some of the forces that turkey is now supporting. in iraq, it's a long story because for iraq there are causes. there are a few factors that make you optimistic about iraq. i think the fact everyone is working together today to fight isis, the fact that some sunnis are fed up with isis and they've seen how isis ruled their areas and governed their areas, they don't want isis to go back to their areas, some of the sunnis, not everyone. the fact that many sunnis have already been working with the iraqi government on a local level to build and rebuild their territories whether in tikrit or fallujah and elsewhere are still problems, but i think there are some segments and some sectors

of sunnis that are working there. some politicians are already involved with the iraqi government. there are still problems with what the iraqi government with people who reject the current system because they think it's inherently favorable to the kurds and to the shia. so they will always oppose it, but they are a powerful force because they can be effective disrupters to the political situation there. i think according to the chief of the popular mobilization forces, the chief himself went to jordan and went to dubai and the united arab emirates. he met with the rejectionists, what many people call the neo-baathists. we don't know exactly what's going to happen, the national coalition which is a coalition of different shia forces and the shia forces and baghdad. they're preparing an initiative

to engage the sunnis, but i think it's a temporary thing, it's an opportunity. i want to conclude by saying that mosul presents an historic opportunity for iraq to resolve and heal the wounds, but i'm not optimistic about whether iraq is capable of doing that. but there is an opportunity of doing that if the u.s. is serious about resolving iraqi problems. they can do a lot with time. >> wonderful. i think i have two points. one, i alluded to already that there's a huge gap between the anti-isis strategy and our counterterrorism strategy, which is generally how we imagine we are containing the al qaeda threat globally. and that gap is leaving a lot of room for the al qaeda movement to resurge. al qaeda and isis are actually synergistic. when one makes gains, all the ships rise and the movement globally is doing very well and is poised to do better, so our

policies need to reconfigure our approach to kial qaeda as we're dealing with isis. in iraq, i very much agree that the threats of a rejectionist movement leave a lot of room for engagement politically. i've been looking at provincial elections coming up as a way to engage. there are some negative indicators leading up to it that there will beinter sunni competition that could go the other was and produce real opportunities for mobilization against the state. i think i read the anbar provincial court put out an arrest warrant for a leader. there are some big cleavages that are moving now. so long as we are tracking them now and engage those issues now, i think we can help iraq stay on a path to a positive future in the wake of isis controlling its cities.

in syria, i would submit the challenge is still very much that al qaeda has penetrated and is on a track to succeed in leading large portions of the opposition and that that is a disincentive to engage them. but no matter how bad or how complicated that situation looks, it can always get worse. and it is getting worse because we are admiring that problem rather than engaging it more aggressively than we are. we do actually have to defeat al qaeda in syria in order to establish conditions wherein neither isis nor al qaeda will gain permanence, not only sanctuary but genuine control of populations and land. >> great. iraq and syria are of course linked, but i think they can be dealing to a certain extent. i'll start with iraq. i think there's grounds for hope in iraq. let me give some history of why

we might have those grounds and then go policy implications going forward. first, really consistently, ever since 2003 and even today, most iraqi arabs want a unified iraq and see themselves as iraqis. they may identify as sunnis or shia, but they identify as iraqis. what the form of that unified iraq is, a strongly federal iraq versus decentralized iraq, that's up for grabs. but number one, they view themselves as iraqi. second, in 2010 or so when we were preparing for u.s. withdrawal, the big concern or a big concern was the kurdish arab flash point. well, it was a point, but it never flashed. there was small disagreements, but nothing terrible ever happened between the kurds and the arabs in any disputed territories. the third historical ground for

where accommodation could be reached is if you think back to when the kurdistan region was on its rampage within oil contracts and it had the coupe of giving six different exploration blocks to exxon, a third of which were in disputed territories, while initially, the political class was just out raged. then within six months, maybe a year, certainly less than a year somehow they reached accommodation. what happened? what they discussed behind closed doors, i don't know if i want to know, but there was an accommodation reached. so going forward, there's one other grounds to hope, and this sounds counterintuitive, which is the collapse of the iraqi finances and oil prices. historically, we see in oil countries when their budgets are

destroyed they institute good reforms. the poster child of that was mexico in 1982 after the debt crisis. because of that, we got an independent central bank. we got a move to outward oriented economic policies and treaty into the gap, so iraq is facing that issue now, and it's kind of under the -- a little bit under the conservatorship of imf and world bank, so there's going to be pressure on good government reforms. now there's a long way to go. this is a government that from 2005 until 2014 doubled its employment and doubled it again and probably added ghost employees. and it's a government that even today has done very little for real private sector development other than saying private sector development is important, but there have been some reforms. so that kind of -- for policy implications in iraq, that says

the international community should remain certainly engaged in the governance aspect. this is not just a counterterrorism exercise. this is an exercise of helping the iraqis figure out the best constitutional arrangement, maybe mediating between communities, helping with legal reform, and of course naturally all the different groups in iraq will have to agree to those reforms, but there needs to be quite intensive engagement this time around. the second aspect. the history and then looking forward, now let me draw on the terrific work by craig whiteside. we saw in 2007 to 2013 the last time aqi and isi were defeated is sleeper cells remained, and it was quite a specific strategy that they followed, which was clandestine infiltration,

assassination of leaders first, and then of legitimate authorities, police and army. during that period, there was actually very little assassination until 2010/2011. very few attacks against coalition forces. what was the target? to undermine the legitimate iraqi government. policy implication number two, this is not just a counterterrorism exercise. this is policing. this is policing and politics. this is making the population feel confident that they will be protected by the government. this is creating a police force and security services that don't prey on the population and that are able to monitor criminal activity. in some ways it's an anti-mafia exercise at this point. so police training, better police, better internal security very important for the future of iraq. so iraq is simple, i think, was the word.

syria -- syria, i tell you, it's really hard. for all the reasons we've said. you want to remove isis so they can't continue to raise money. it's a mistake to talk about mosul as being the last stand. we have the entire western euphrates valley, the oil fields there. lots of good revenue raising potential. so you want them out. al qaeda is gaining strength. they're rebranded. they would claim they're not al qaeda now, but we're all considering them to still be al qaeda. they're getting strength. and because the international community did not fully engage early on in training opposition forces, they've become an important part of those opposition forces. the third element with syria is i don't really think that we settle the issue as long as assad -- certainly as long as assad is in power and then it's debatable if we can settle this

if his regime is still in power. i'm not enough of a syrian expert to go that far. it's actually a very tough case. because it is a very tough case, the international coalition is doing what it's focusing on in its interest, which is counterislamic state, thinking about raqqah, but that is going to breed further problems in how we settle that, i don't have good ideas. >> i'll add one more before we turn it over to questions. i don't think you can unlock a lot of the things in syria on the ground independent of the regime while you still have turks and kurds shooting at each other. the interlocking on top of this, the turkish-kurdish cleavage, and insurgency as well, and how that bleeds over into turkish actions inside syria, you can't unlake what would make sense to probably a lot of people on this panel to try to facilitate a local cease-fire between arabs

and kurds. cooperation on, say, joint governing of areas in conflict, while the main backer of one side will prevent that. so you need, as the united states, to try to expand the scope of your own responsibilities to try and take upon what is a strand in the thread, a very long and old thread, of this conflict that has spilled over the border into syria, which is the pkk, turkish government fight that is actually raging at the moment. so on that happy note, those are easy policy recommendations to implement. we have about 25 minutes left. i think it would be great if we could turn it over to the audience here for questions with the caveat i'm the moderator and i'll use the prerogative to try to limit the questions to one or two sentences and they actually end in a question mark. i'm sure there was a lot of things that were said about things you're interested in, but obviously we'd like to get as many as we can. with that, i open the floor.

yes, sir. right here. maybe you can introduce yourself as well. >> i'm with the atlantic council. i'd like to compliment the panel for a very, very thorough and comprehensive talk. my question is this. could you comment on the casualties that all sides are taking that we know about, coalition, civilians, al qaeda, and i should say the islamic state and the command and control that's being used on the coalition side and the involvement of the united states? because it seems to me that is very, very, very rickety. >> wants want to go first? >> i don't have good numbers on the casualties, but iraqi forces at one point a week and a half ago were complaining about a lack of air strikes because they were taking so many. the way i've metabolized that is to recognize when there were

four or five axes on advance of the city, that's a lot of power heading toward mosul at the somtime, coming into a lot of enemy contact with isis, and there are a lot of air strikes being called in and most are getting covered and yet the casualties on the coalition side are still very high. isis is also executing a lot of suicide operations, so it is also taking a lot of casualties. i have not encountered that many reports yet of troops in contact. these still look like explosive and either mobile or static defenses that are being run into, and i would assume that isis is in fallback positions that isis is trying to use civilians as human shields and is executing those who resist. among those who are resisting are retired iraqi army officers. whenever i hear that phrase attached to mosul, i think baathist cadre and those who might be in a position to launch

an armed resistance not only to the state but to isis. the civilian and retired military demographic in mosul is the one taking the most casualties. when it comes to c2, the coalition, i was skeptical about how well the c2 would come together, and it's performing very well. i think it's been well designed and all parties that are participating have sign eed ont it. the spoilers at the time are not the kurdish and iraqi force coalition elements or even the tribal forces fighting along shia forces. it's the independent operations that could break apart the plan. >> and c-2? >> command and control. who is designing and orchestrating and leading the thing. >> the question is, american involvement, who is engaged on

our side and who is in control? operation resolve is the command i would point to. there are special forces missions. there are air component missions and there are partner capacity building efforts. all of them are engaged. partner capacity building forces are forward in a -- i think i'm tracking the lowest echelon of the battalion level. so, i can't necessarily speak to whether or not u.s. forces are actually on the advance, i don't know. but we are heavily integrated into the indigenous forces who are actually the ground elements. >> anything to add? >> i have a couple things on casualties. we should expect very high islamic state casualties. historically, when we look at their rosters, they continue to pay families of fighters who have been killed. we are able to identify from the roster, how many are killed.

we saw in anbar in 2005-2006, about a third of them had been killed. we saw comparing mosul rosters from 2007-2009, even a higher proportion had been killed. they are almost expendable to leadership. we are seeing casualties inside mosul from resistant movements being executed and then we should expect some residual casualties. isil has been wiring cities as it leaves, so people want to go home. so, they will, even if they are told they shouldn't go home, they will go home, open a refrigerator and pick up an object and there will be an explosion. i haven't tracked it all, casualties on iraq or other coalition forces. >> i can address one aspect outside the iraq operation. it was largely kurdish affair

with american and special ropitions. that, you know, there were hundreds of kurdish casualties, upwards between 300 and 400 with injuries well over 1,000. it's unknown how many the islamic state took. they don't advertise this. the documents we could use to track it will probably be out in ten years to look back and get a better sense. it gives you a sense of let's take raqqah as a model. what raqqah would look like and this will not be an easy affair. this will require a significant amount of ypg forces to do it and willing to take casualties to do it. when you get back to my policy recommendation, kurdish grievances in addition to the worry about the political tensions between arab kurd is how do you turn around and tell the ypg you have to leave a town where you just lost a large

amount of your people? it becomes politically problematic even if they don't want to stay. they will put allies in there and try to control the city. not without reason because what we are asking them to do. next question from the audience? in the back. >> hello, andy with international center for religion and diplomacy. >> can you speak up a little bit, sir? >> you all spoke on the problems with having isis have ground control with taxation and funding their efforts and also problems with having foreign fighters have avenues to enter syria. what about the foreign funding that's involved? what do we do after isis is routed and defeated and removed from current positions when they still have funding? do we expect as the international community sees defeat, they will lose funding complicitly or there will still

be a funding terrorist organizations with serious capabilities? >> howard, you want to take it? >> if i can ask you after the answer, expand upon how we can begin to train up local forces to do the things needed. >> sure. so -- so foreign financing is something we really haven't had to worry about much. because they, historically, and even today, have not raised a lot of money from foreign donors. the al qaeda model, the wealthy gulf arabs funneling money to afghanistan and pakistan doesn't really apply to islamic state. let me refer to documents. what we saw in -- i'll go three periods. i'll star with anbar, 2005-2006. they are meticulous in recording in their ledgers where their revenues come from. approximately 5% of their revenues were marked as donations.

differentiate between foreign and domestic. we assume those were mostly domestic. if we look at the ledgers from mosul, the peak of their -- the second peak of their power in iraq and headquarters in 2008-2009, we get the same proportion from donations, certainly less. then, if we fast forward to the islamic state, 2014 to the present, we can break down their sources of revenues into money they held from banks in territories they captured. that was the largest single injection and oil revenues, that's local. that's from -- that's originally from smuggling out through turkey and we think curd astack. that stopped early on. most oil revenues have come from internal sales and collusion with the assad regime exchanges. oil revenues and taxation and extortion and smaller amounts

kidnapped for ransom and archaeological artifacts. they did get money from overseas fight eers who bring money and other scams they would use. but, really compared to the bulk of the revenues, very small. so one of the -- one of the questions that's been raised as we kind of think about what is the future of islamic state look like after it's ejected from mosul, raqqah, that it then turns to foreign funders. we could be wrong. can't predict the future. baked into their doctrine is don't raise money from foreign governments because they will tend to control you. so, my guess is that we still won't have to worry that much about foreign governments. that's the first thing. the second thing is, thinking from a purely kind of very cynical view, i think it is in the interest of the gulf

countries and other potential donors to make sure that whoever is donating money isn't donating to the islamic state. they are part of the finance group, which is a multi-national group that looks at islamic state finances. it's hard for them to justify support for islamic state. it is easier to justify support to al qaeda. they can say al qaeda is -- no longer part of al qaeda. it's a legitimate part of the anti-assad coalition and we support that. you can see them saying that. it's much harder to see them not cooperating in the counter isil fight. i don't think we'll have a problem with foreign donations on a large scale. >> just want to agree on that. even al qaeda and syria resists foreign support.

they would say, look, i'm not going to look, you can put it in my pocket, but i'm not going to take funding from outside. they worry a lot about infiltration, about people within or other groups that would be influenced by the donors. i agree. isis is more extreme on that. they do a lot of vetting for people, even within their organization that have deep pockets. >> speaking from the turkish perspective, one of the successes of the coalition that doesn't get mentioned a lot because we follow the military day-to-day is the counter financing task force. some things you see in turkey in addition to the border being cut off, before that, subsequent efforts to block the border was efforts to try and control establishment of local bank accounts along the border to prevent say somebody who

a fighter to then transfer money to a local bank account, then get the bank account, get the money, and as they go croesus, the islamic state takes every from them. that is a potential source of revenue. it doesn't get a lot of credit, but the counterfinancing task force is quite important. sir? right here. >> thank you very much. alexander. great panel. i heard hassan hassan talk about on schedule. heard other government officials here in the u.s. talk about on schedule. later, you talk about fighting for four months, if i got that right. my question is, on schedule, that assumes there is a schedule from beginning to end. so, what would be the schedule for planting the flag in mosul? i mean, i'm just curious. we keep hearing in the press. so what's it going to look like.

for jessica lewis, you mentioned shu dadi, i'm just curious, what happened after? they fled, but that was 2015. they fled south, that was 2015. what happened later? is it still empty? did they come back? that might shed light into how it might play in other places. thank you. >> yes, sir, thanks. >> this is what the iraqis and americans are saying. they are on schedule. it's been a little bit, i think two or three days more than two weeks into the fighting and i think it's been, you know, the americans were saying mosul forces did their job on schedule. meaning the peshmerga has reached the eastern frontier and cleared some of the important areas. the counterterrorism force, for example, was expected to have difficult terrain among the southern frontier. they have done a great job in

that area. for example, it was supposed to be a difficult, tough fight. they took it a couple days. they had to pause for a day or two, but they reached it. the problem is -- and this is -- this relates to the problem of casualties. there's a problem, a point to be made about transparency and the u.s. obviously and iraqis want to show that this is a very clean fight and they want to go in there as smoothly as possible and control the reporting. not in the sense that -- but they utilize the fact that the reporters cannot go so far into the front lines. so, i think there is -- there's that problem. once they reach the center of mosul or say they reached the center of mosul and try to de-escalate or reduce the media

coverage in that area, it seems like mosul is going very well. i think that's a problem. we always have to be attentive to the local dynamics of what's happening inside, whether people are agitated by the forces coming into mosul or welcoming the forces, because we have seen a lot of disinformation throughout the fight. i always don't pay attention to the numbers because i think the u.s. exaggerates the numbers. isis also does exaggerate the numbers from the other side. there's a lot of disinformation. a lot of reporting, i could watch fact checking reporting about isis. there's so much already happening. rebellion in mosul that never happened. that's just a lie. that's not how isis works. some of the reports echo reports from two years ago. it seems like it's taken from one page somewhere. so i think always take the

reporting with a pinch of salt. i think so far, so good. >> my answer is fairly short. it's a wonderful question what's happening over the last year. i actually haven't looked, but for exactly the reason you framed, it could tell us about how the situation will play out a year later, i'm going to do so and i would be happy to share with you in the next conference. >> i don't know the answer to that, either. anybody else have a question? i saw your hand in the back corner. in the back corner, behind the column. there you go. >> hi. i'm name is hamad and i'm with the arab american institute. my question is, currently there is a record of 64 million feoff refugees worldwide with a significant portion coming from

syria and iraq. how should the international community support iraq and syria in neighboring states including lebanon and jordan in achieving stability with the high number of refugees after isis is defeated? >> great question. does anybody have thoughts on the refugee issue? >> i'll go ahead. it's a great question. it's a very difficult question. i don't think there's one coherent answer. there's been -- so, let's start going in stages from kind of immediate assistance to longer range. immediate assistance, there's a lot of pressure on lebanon, jordan, turkey, the main receiving countries. it's -- they didn't ask for this burden, they happen to be in the neighborhood and received the burden. for the immediate, i think international assistance in terms of shelter or food,

especially schools, education for children is merited. i don't think that international assistance has been at the level that it should be. we can be very cold and say, well, the adults, it's kind of too bad what happened to them. we have an entire generation of young, middle easterners who could be the doctors, engineers, artists of tomorrow and are, instead, the refugees with an uncertain tomorrow. that's the immediate issue. second, i'm going to assume, based on fact, that most refugees want to go home. but, we also know that refugees tend to stay refugees longer than they think they will. now, we face a difficult issue, which is that -- do we try to help jordan and lebanon and turkey integrate those refugees, make sure they have work permits

allow them to fully take part in society? that would be good for refugees. it could be in the long run good for those economies because they have more workers, especially young people. it could be good for both. at the same time, you have cultural issues and social issues. that is one decision point we have to consider. if we don't help them integrate, then the question is, where do they go? well, europe has decided it's had enough. at least it's had enough this quickly. and the united states is slowly taking the middle eastern refugees. we take other refugees. that kind of is a -- the only other option for them is to speed -- to bring stability and security back to their home regions. so, that is somewhat happening in iraq. that goes back to the policy implications.

a governance reconstruction, the idps and refugees, most of them will tend to go back, if they haven't been away too long. syria, i think if you want to put it in humanitarian terms, we have a strong argument for greater international involvement in the war to the extent that it can bring stability to parts of syria. it's going to be very hard to put syria back together. so the question is, are there areas that we can stabilize in syria? more cooperation with arab forces, arab opposition forces, more cooperation with the kurds. we can stabilize the people who want to go back, too. so, i think that's way above all of our pay grades, i think. but those are the dilemmas governments have to look at with them. i talk about the middle east refugees. i didn't talk about the other 50

million, is it 10 million displaced from syria? 3 to 4 million displaced in iraq? that's enough to deal with for now. >> just add something quickly. there seems to be an interesting week in terms of refocusing that question of refugees, particularly from syria. i want to point to two items, one that lebanon has new political leadership this week and the feeling about syrian refugees is quite contrary to the very constructive argument you just made about option said that could be pursued to their benefit within their adopted countries. i think lebanon is very much headed in a direction right now that could make that problem more acute. so, i'm refocusing right now upon regional hugs where refugees are collecting and less

upon europe, which i have been focusing on in recent months. the other place where i point is morocco. morocco is having a weird protest movement right now that i think also speaks to the fact that one of the original arteries for syrian refugees escaping was to algeria and from algeria where they couldn't stay on their visas from syria, that were generally easy to get, they just went to morocco. those are places where the refugee issue has been stable is becoming unstable and therefore i want to highlight there can be potentially be more than just a broad brush statement about how to help them. i very much agree, giving them back to a vital position in their home country is the ideal, i think, in the immediate term. we are going to have to deal with places we haven't been talking about lately. >> i think the final question,

you have been very patient. then we can begin to wrap up. we have about five minutes left. the final question from this woman right here. >> thank you. my question is about al qaeda's movements. traditionally, zuawahiri and bi laden were focused on the establishment of a state, a caliphate, as a distant promise, aifying force for al qaeda's ultimate goal, which was a globalized insurgentacy movement. given the recent movement in syria, is that changing? is al qaeda trying to become more of a zarqawi model of state presence, sectarian conflict? how is the -- like what are al qaeda's ultimate goals in the syrian conflict? >> about four minutes and i'll wrap up. >> i think in syria so they banned in al qaeda. they are still -- they have the philosophy of al qaeda, the original one, which is that

their mission is to popularize the idea of jihad. you need to make normalizing it with the community and encourage people to join jihad rather than enforce some sort of governing body on them. they rely a lot -- they focus a lot on consensus. unlike al qaeda, sorry, unlike isis, although the idea of a state and how they pursued it in iraq goes back to a letter sent by zawahiri in 2006 when he congratulated him on the formation of the mujahadin council, which was a al qaeda group joining other iraqi forces to look more iraqi. he said this should be to establish a state in the sunni areas in iraq and that could

develop into a caliphate, and then you expand the jihadi ways in his words, into a secular countries around the region. then after that, confrontation with israel. thal four steps that zuwaw hery were sued were laid out, were pursued by isis. i think it's still a hybrid between the two. they want to establish a governing body, but don't want to establish a state yet. >> just adding two points. it is interesting to me he put out a statement directed at members of isis who might cleave towards al qaeda as isis loses strength. zarqawi was fabulous. a very pro-zarqawi message. really capturing the idea that iraqis can be part of al qaeda again. so, just to juxtapose the two in relationship, that is how he is

handling the legacy of zarqawi now. playing on the fact he had been part of al qaeda's movement. the other, reinforcing, al qaeda does not imagine itself to be the governing entity. it imagines itself to be the silent vanguard. but its affiliates, by another name, can be governing entities. it would be consistent with the current program for an affiliate that doesn't bear the al qaeda name to govern. i do think that's ultimately the direction they will head. >> i think with that, we ended right on time so everybody can get back to work today. i want to thank the panelists. please join me in thanking them. and thank you for attending.

supreme court associate justice clarence thomas is scheduled to make a rare public appearance tonight at the federalist society here in washington. we'll have our cameras there, and expect to bring that to you live starting around 9:00 eastern on our companion network, c-span. the justices recently heard oral arguments in a case that involves discriminatory lending practices. we'll bring that oral argument to you friday night at 8:00 eastern on c-span2.

the national book awards took place in new york city last night. hosted by comedian larry wilmore. our cameras were there and we'll show you the event this sunday at 10:00 p.m. eastern on c-span2's book tv. as washington prepares for the start of the 115th congress in january, freshman representatives are making their way to the capitol. we caught up with one of them recently. >> we're here with congressman-elect ted budd of north carolina's 13th district. before congress, ran a gun shop in north carolina. how does one go from running a gun shop to congress? >> i think of myself as an entrepreneur who likes to create value for others. we raised our hands, volunteered, had a big primary, and people liked i had never been in office before. >>ia came in campaigning as an outsider. how do you plan to keep that label now that you are actually a member of congress? >> again, you have to create value for people. you say, look, i'm inside now,

but do i represent the people well? that's what i want to do. i want to come home, i want to look people in the eye. i want to say i'm representing your best interests. >> what are a few of those priorities you have legislatively? >> they think government is doing things it was never intended to do. too intrusive in business, in personal lives, and especially businesses. i'm even having entrepreneurs come to me and saying i'm have toi ing to reduce the size of my business and turn them away and not hire to be profitable, such as obamacare and things like that. >> you own a gun range. you're peat good at shooting a weapon. are you planning to use the gun range on capitol hill. >> i hear there's one in rayburn. i'm new to the place, so we'll see. i'll find my way down there before too long. >> talk taany of your new colleagues about doing that, going down with you? >> i been campaigning for a while. they may be a better shot than me right now. >> planning on bonding with some of the new colleagues? >> absolutely. >> made new friendships in the

hours you have been here? >> even today, people from both sides of the aisle. this freshmen class should be fun. we make great friends in the freshmen class. >> and your committee priorities as you go through the process. what are you hoping to get. >> we're not making any commitments at this point. we don't know and it's presumption at this point, but as an entrepreneur, i can offer a lot of value and different options to different committees. >> ted budd, thanks for the time. >> follow the transition of government on c-span, as donald trump becomes the 45th president of the united states. and republicans maintain control of the u.s. house and senate. we'll take you to key events as they happen, without int interrupti interruption. watch live on c-span. watch on demand at c-span.org or listen on our free c-span radio app. >> c-span, where history unfolds

daily. in 1979, c-span was created as a public service by america's cable television companies. and is brought to you today by your cable or satellite provider. >> now, a discussion on databased collaboration for health care researchers and practitioners. medical industry executives and government policymakers were among those speaking recently at the fourth annual health care of tomorrow conference, hosted by u.s. news and world recoport. this is just under two hours. please welcome margaret mannix, executive editor of u.s. news and world report.

[ applause ] >> hi. welcome, everyone. welcome to the fourth annual u.s. news best hospitals, hospital of tomorrow forum. actually, we have taken a great big leap forward. after consultation with many of you, we decided to expand the conference framework to better reflect today's dynamic health care industry. we're now calling this event health care of tomorrow. the new name underscores the industry's commitment to developing a robust continuum of patient-centered care. of course, that's not a surprise to all of you. have hospitals have become the hubs of vast health care networks that reach into many corners of the community. from urgent care clinics to ambulatory care facilities to nursing homes and rehab centers. and our gathering here now reflects that. as you evolve, we will evolve. another exciting change we made, children's hospitals have long been a focus for u.s. news.

and this year, we have created a separate children's hospital track. we have also established a children's health care of tomorrow advisory council and we thank this distinguished group of leaders for offering advice and expertise for our new pediatric spotlight. we would also like to welcome the many children's hospital executives who are speaking this week. they hail from the children's hospital of philadelphia, cincinnati children's, children's national, texas children's, stanford children's, and nationwide children's, among others. and of course, we would like to thank our standing advisory council. made up of experts from the nation's top adult hospitals, a special thanks to them for their insight and suggestions. we would also like to offer a very big thank you to the premiere sponsors of this event. athena health, microsoft, and siemens. i'll be your emcee over the next couple days, making sure the trains run on time and you all

are aware of the many sessions and networking activities you all can participate in. now, just a couple of house keeping notes. we're live right now on c-span2. later today, you can find this session on c-span's website, c-span.org. wi-fi is available to all of you on the network renaissance conference and the password is u.s. news hot. you can follow us over the next three days on twitter, and we encourage everyone to tweet live, #usnhot16. you can also find us on facebook, linkedin, youtube, and instagram. u.s. news reporters are also covering the event, so please visit u.s.news.com/hot to keep up with coverage and get a summary of the sessions you may have missed. videos of our keynote sessions will also be posted there. tomorrow morning, we begin bright and early right back here with several exciting breakfast roundtables and a full day of panels, workshops, and case studies. and don't miss our keynote

luncheon, which features what promises to be a fascinating discussion about how technology is tranls forming health care. at the conclusion of this afternoon's program, please join us upstairs in the lobby bar for a welcome reception. sponsored by ut southwestern medical and road map. now, let's begin our program. it gives me great pleasure to introduce our first speaker. brian kelly, editor and chief content officer of u.s. news. under brian's leadership, u.s. news has undergone a remarkable transformation. born a weekly news magazine, u.s. news is now a global digital news and information company that provides people with the knowledge, data, and know-how they need to make life's most important decisions. and as you well know, many of those decisions concern their health. from choosing a doctor to a nursing home, to an insurance plan, to a hospital. and brian has made usnews.com a

must-read website for those consumers. over 30 million people visit usnews.com each month and more than 5 million are seeking our health rankings and advice. ladies and gentlemen, please join me in welcoming brian kelly, editor and chief content officer of u.s. news. >> thanks, margy. welcome to washington. sounds like a punch line these days. let me start with a prediction. i predict three things will happen here six days from now, tuesday. i prith that something very interesting will happen. how is that for safety? i predict that whatever happens on tuesday will not be over. we will be dealing with the consequences for a long time.

and i predict that on wednesday, life will go on. for all of us. i'm one of those stalwarts who believes that american democracy will survive. you will survive. we'll see. but -- [ laughter ] >> but i believe that the businesses that all of us are in will also survive, however, they will be affected by whatever it is that happens and i am not going to predict whatever it is that happens. but it is -- it is, in fact, one of the reasons we're here. we talk, you know -- the theme here is healthcare of tomorrow, we try to be forward looking here at the moment maybe the most forward we can look is about two months, but we're going to look as far forward as we can. you know, this is clear one aspect of this that's clear, we will talk about this a little later, i have great panelists coming up, but, you know, you cannot separate healthcare from the federal government. so we understand that, we need

to understand what that means. we're going to rye to help you and do our part to move that forward. but there's so many things going on in the healthcare industry right now, you know, as marky said the traditional roles of hospitals is dramatically changing, the system increasingly awarding better care, preventive care, tests and procedures. you have had to learn new competency and rethink age old practices, we've also witnessed disruption, a flurry of healthcare providers whose proven, both unproven, massive consolidation, the adoption of new payment models, a mandate for greater intra operability. i have a lot of problems in my business, the media business, but we are not here to talk about that is correct we're here to talk about the problems in your business and i look at what you've had to grapple with and

maybe i don't feel like i'm in such bad shape. medicare continues its push towards value-based care, 30% of payments must be tied to those models this year and 50% by 2018. good look with that. cms released its star ratings for hospitals. i know somebody else in the rankings bus i will hold off on that for a while. only 2% of hospitals earned the full five-star score. we will have more to say about that later. cms has expanded its bundle payment program for cardiac care, hip replacements, not insignificant. in another part of the world there has been a rash of cyber attacks on hospitals and healthcare systems, we have some people that dig into that a little bit more. aetna, united healthcare, humana all announced next year they will pull out of exchanges provided by the affordable care act. story to be continued. last but not least cms is

changing how physicians are being reimbursed, we always want to keep some emphasis on physicians because that is where the rubber meets the road in this industry. over the next few days the hospital executives and other leading experts that we've assembled here will help you transverse this rocky landscape. some will look at the big picture or provide a new perspective on what to expect down the road, others will go into specific issues and give you guidance and lessons learned from their own experiences. you will have many opportunities to network and share best practices with your peers. you will find many of them confronting the same problems and challenges you are. as you know u.s. news has followed the hospital industry closely for nearly three decades. in fact, this year is the 27th year of our best hospitals rankings. as we continue to expand our role publishing consumer health data and advice, in addition fairly recently to custom products for hospital executives, we're constantly

seeking out the best measures of success. to that end we're convening a cloak weem on friday morning which i will moderate, no one told me that. wait a minute. we will wrestle with the best practices for assessing hospital quality, safety and performance. with the controversial star rankings front and venter we want to bring together the key players from the assessment world for a lively and we hope productive discussion about what works and what we can do better. joining us will be some of the nation's leading hospital quality experts from harvard, johns hopkins, northwestern, yale and more. maintaining our tradition of transparency we will also have a session on our own rankings and ratings and our chief of health analysis, ben harder will outline our plans for the 2017, 2018 rankings and beyond. our goal for this conference healthcare of tomorrow remains the same, to create a forum where the best minds among

providers, payers and policymakers come together with the shared mission of improving consumer health. i'm proud that this has evolved into a provocative but civil forum that allows health professionals make progress on solving the key challenges we face. there are few subjects we cover at us news that are more important. i encourage you to engage in the formal or informal dialogues among the industry professionals, policymakers and medical experts we have gathered here in the nation's capital. thank you very much for joining us. [ applause ] >> thank you, brian. and now i am so very pleased to introduce dr. craig ven ter, widely recognized as one of the preeminent scientists of the 21st century. craig played a critical role in the sequencing of the human genome paving the way for

numerous new their piece and treatments. through the ven ter institute trag is continuing his ground breaking veerch and over its synthetic jen inappropriately mix he is developing other technologies to benefit people, the environment and industry. while craig is a visionary he is also a low back to the scientists and explore remembers of the past. he has studied the oceans, he has explored extreme environments from polar ice to deep sea thermal vents producing still more impressive findings. now as co-founder of human longevity he and his team are searching for ways to extend the human life span. please if i have a very big hand for craig venter. [ applause ]

>> thank you so much. very kind introduction. it's a pleasure to be here today to tell you guys a little bit about what we're doing at human longevity to increase the healthy life span. if i can start with the first slide, this is a picture of human longevity in la jolla, california, it started about two and a half years ago based on the premise that we need a very large number of genomes with associated phenotype and clinical data to make sense out of the genome. we're trying to change the paradigm from what it is in healthcare today to being reactive to trying to change it into being proactive. so we only see people without obvious symptoms or obvious disease in contrast to most of you see people that at least think they're sick. so we're trying to use the

genome to make it much more predictive in the future but right now we're collecting all this data to see if we can even take that interpretation further. the reason for this is it looks like it applies to a fair amount of this audience, if you're between 50 and 74 and you are a male, 30% of you won't ever reach the age of 74. if you are a female 20% of you won't reach 74 and the key reasons for early and premature death are cancer and heart disease, they are roughly two-thirds of the reasons slightly higher cancer rates in women and slightly higher heart disease in men. so if each of these became predictive, early detection and prevention it would have a tremendous impact. this is sort of the survival curve and how it's changed over the last century, over half the

population 1900 never lived past the age of 57. we're getting past the 80s and there's no clear cut upper limit as we look to all these tools for trying to expand what we call the healthy life span. so 15 years ago when we published the first version of the human genome it cost $100 million to sequence that, it took nine months, we had to build a $50 million computer to analyze that and so it wasn't a highly replicable event. but just a few years back sequencing technology changed dramatically to where it was under $2,000 a genome and that computer that cost $50 million you can buy a card for your pc for $100 that does almost the same amount. so the changes are in technology, the changes are in

distributive computing and the third key component is machine learning and i will show you how we put these components together. we have three sites, the main site is in la jolla, california, we have a site in mountain view and a site in singapore, mainly for attracting key inn format particulars people. . we have phenotype and clinical data on those and many people thought genome mix wouldn't be a big data problem but we are 4.4 pedabytes on data just of as, cs, gs and ts. in 2012 you can index and copy the entire internet with 12 pedabytes of data. you can imagine when we have over a million genomes the data problem will be enormous.

a while ago we published a paper on characterizing the first 10,000 genomes to see what they had in common. one of the biggest surprises was all the common variants in the human population saturated after about 8,000 to 9,000 genomes. so the things that other people have been measuring associated with disease we all basically share. and so the key thing is to come up with the rare variants that are actually associated with your unique traits and with the cause of disease, but having all of this data allows you to do unique analyses, for example, we can find out how much we have to sequence to get extremely accurate sequence coverage with a very low false positive and low false negative rate and i think we've achieved that now and we have the first whole genome sequence that's validated with hmp 38 and 19 in the world.

so one of the things as we sequence new genomes on average we found about 8,000 rare variants. that's 6.4 billion letters in your genetic code. that's an average. i was just on the chelsea handler show giving her her genome report if you watch that, she actually had 15,000 rare variants but a very mixed ethnic and genetic background, but most of what we're building the database are these rare variants. we can also look at billions of data points and we can ask questions like are there sites in the jie inappropriately that can't not tolerate mutations and become compatible with life. when you see one of these downward spikes it's a place if there is a mutation in that site in the genome it's incompatible with somebody being alive.

these are important kind of findings because we're finding certain rare variants in the population disappear with age. that means if you have those they die out with you prematurely. there's lots of sites we can look at, just looking at the whole collection of trans membrane proteins, the part that sits in the membrane can take very few mutations because if it changes the charge the protein would pop out of the membrane and be nonfunctional. so what can we do with this data today? it used to be you had to have large families with disorders that took decades and decades to sort out. today we need a single patient, for example, from a children's hospital to sort out a rare disease. it helps if you also have their parents, it's called a trio. here is a case from the children's hospital in san diego, it's a very rare disease

called delleman's syndrome, nobody had worked out what the genetic basis of it was. if you look at the mri of the brain you can see the brain is quite a bit disordered and the child also had tumors covering his body. so we knew it was going to be a mult multijen nick disorder. it was interested looking at his parents' genomes and things popped out immediately. whenever you see these orange bands that's where the parents had exactly the same genome sequence. this tells us that they're very closely related to each other. in fact, they were first cousins but they grew up in a small village in mexico with lots of inn breeding to the point that now these chromosome regions are identical. the impact of that is if one of them had a real illegal on that part of the genome now those

turn into disease ileals and that's what happened with some of these neurological development disorders. also we had a rare variant in the one between, that's associated with elephant man's disease and therefore might link to the tumors. it's very interesting, we show it to make the point that neither parent had this mutation. so it's only in the child's genome. so in addition to all the information you get from each of your parents genomes, we also have several hundred to several thousand spontaneous mutations that in some cases like this can cause a rare diseases. with cancer we have the most comprehensive jean mick based cancer program in the world, we sequence the entire person's genome, we sequence the genome with a tumor to extremely high coverage, we sequence the r & a

from the tumor to understand which tumor mutations are actually expressed, we isolate the t cells from the tumor and sequence the entire t cell repertoire. we also characterize which of those t cells match up with mutated proteins. so, for example, here is a patient with hpv 16 caused head and next cancer. we found 25,000 mutations in his tumor. by doing both the genome and the tumor genome we get a total mutation nl burden which is turning out to be very helpful. we found 315 mutations and protein coding regions so these create the so-called neo antigens. if you think about that with tumors you get these mutations that create proteins that aren't part of the normal human repertoire. that's why if you have an intact

immune system your immune system attacks these proteins and generally will kill the tumors. if you have an inefficient immune system or it's suppressed then tumor growth can take place. but we're constantly having mutations in cells and clearing those with a good immune system. for example, it's not such a problem in washington but in la jolla we get a lot more sunshine and if you go and sit in the sun for about an hour you can get as many as 10,000 mutations in your skin cell genome. the fortunate thing with skin, we replace it on an average every two weeks. that dust that accumulates in your house, that's you. that's why there's always more coming no matter what you do. so we're constantly shedding that skin, but other cells

aren't so easy to shed and that's where our immune system comes in. this individual had mutations in his genome and three genes associated with a high risk for cancer, he had a suppressed immune system and we found hpv-16 present in his mime row biome putting him in a situation where it would probably be more likely if he didn't have cancer than if he developed it, but the neo antigens give us targets for knowing which drugs will work, which ones won't, but they also give us the ability now to develop new vaccines specifically for that individual and theaeir cancer. we are just starting this program now between human longevity and ucsd doing our first test this fall. what we do uniquely is we validate the neo antigens making sure there is a t cell cologne that does recognize that mutated

protein which we think will greatly increase the efficiency. we set up our own clinic, we call it the health nucleus, it was set up for large scale phenotyping where we do a wide variety of tests, you can see a list here, everything from sequencing the genome, the micro biome, measuring thousands of chemicals and going through a quantitative mri imaging, ct scanning for d echo, et cetera. i will walk you through a few of these things. our key instrument that is really valuable is the 3 t mri and we have two of these, we have a ge 3 te and a new siemens 3 t mri and the resolution from these is amazing, but the key change in the space happened just in the last two years, scientists working with dale anders at ucsd developed this new imaging analysis that just

looks at the water differences in tissues and it allows -- as you will see in a minute -- blood vessels show up readily without any contrast media and tumors light up like light bulbs, so it's called restriction spectrum imaging. here is a case of a few more totally thought to be healthy individual came in, just to go through the health nucleus, we found a 5 centimeter tumor under his breastbone. you can see in the image on the right it literally lit up, his tumor was removed within a week, it was a stage 1 thigh moment ma but it was just at that stage where it was starting to penetrate the tissue, this is just the size where they start to be dangerous, but detecting it early he went home a week after discovery completely cancer free. if he waited another year or two

the outcome would have been totally different. the straight mri imaging now allows direct diagnosis of prostate cancer just in the mri without any contrast media and here is a few cases that was published by our radiologist david cairo and his colleagues at u schdsd. you can see where it shows up bright yellow that's where the tumor area is and of it totally correlated with the histopathology on removal of the prostate. so they can actually get gleason grades right off of the mri in as little as 20 minutes without any contrast. here is another one that makes it even more clear cut, you can see the bright yellowish orange region that totally corresponded to where the tumor s the nice

thing about these mri images they can now be lined up with echo images for biopsy in the area where the tumor appears to be instead of just taking random beepsees. we are now diagnosing late stage prostate cancer in about 10% of the males that are over the age of 50, many of them with completely normal psa and had no idea that they had prostate cancer. these are the types of images that we get from the brain vasculature, again, with no contrast media so we can tell you how good of a shape your brain is and the blood flow. occasionally we find things like this, we find aneurysms in the brain. so two women in their 30s had these aneurysms, usually people discover them when they pop and they bleed to death. most people know somebody that died from a brain aneurysm.

one in 500 people in the population have these. now they just show up without any contrast media quite nicely. we found another surprising thing, so two women had these large ovarian cysts, this is one the size of a softball and she was completely unaware of it, the other one had the size of a football and was unaware of it. even if these are not cancerous they are in a dangerous stage because they can twist and women quite often present in the emergency room with massive internal bleeding because of these. one of the exciting measurements is when we get metabolic measurements now right off the pli, we can measure the amount of fat in your liver. so normal is 4% or less, we have had people now as high as 38% with completely lack of awareness that they had any metabolic disease whatsoever.

at that level they would be up for liver transplants within a decade and there is a disease called nash, it's not necessarily associated with alcohol use, nash is non-alcohol related liver disease. i was on a 30 mile bike ride with one of the world's experts on organ fat and we were 15 miles through the ride and he told me, you know, exercise won't reduce your organ fat. and i said you couldn't have told me 15 miles ago? the only thing that will is calorie restriction and obviously exercise helps with calorie restriction, but it's very dynamic and it can change quite dynamically. so we do a variety of things for a brain and neuro testing using the mri we get these incredible images using another tool developed at ucsd called

neuroquant that measures the volume of 20 different brain regions, it's very easy to diagnose alzheimer's disease with this technique. i will make you all experts here. if you look at the one that says normal and you look at that yellowish gland that there's two of, that's the hip owe campus, that's where changes show up first. if you look at the one with alzheimer's disease you can see all kinds of shrinkage around the brain but that little yellow area has shrunken tremendously and there's voids around that. so that's where it quite often shows up first. we are now at the point combining the human genome with this type of neuroimaging where we can predict the future appearance of alzheimer's symptoms 20 years before somebody has those. gives a lot of time for development of new preventive

medicines. we find a variety of different types of brain tumors. this is just a manage yoem ma right on the top of the brain, here is another vascular type tumor. the main problem with these is that they tend to bleed and cause strokes. we do a lot of unique cardiovascular testing from 4 d echo to ct scanning to people wearing she is little strips that records their ekg for two weeks and that's been responsible for a lot of our discoveries. the 4 d echoes if you haven't seen them are really incredible, you can see all four chambers of the heart, you can look right now one of the chambers and see the heart valves. by measuring the doppler shift you can see if there is any blood regurge tagt so none of the physicians in the health nucleus use a stethoscope anymore because the techniques

are far more accurate. this is the ct picture, this is my heart, we actually use this for hr classes just to remind them that the ceo has one. [ laughter ] >> but we can see the blood vessels very accurately and quantitatively and so these tools really give us something that's quite unique. the two week remote heart monitoring has really been amazing and we've discovered a number of cases of episodic atrial fibrillation, some for as long as eight hours with people being completely unaware that they were having it. perhaps it was while they were sleeping. so these individuals obviously are at very high risk for stroke so just putting them on an anti-coagulant certainly changed their risk profile. a few individuals had complete

episodic heart block where their heart rate would go down to 20 beats per minute and somehow they were completely unaware of it. i think i would notice if my heart started going that slow, maybe it was dozing out i wouldn't. so they are at risk for sudden cardiac death, they are now on pacemakers. we get these beautiful pictures of -- that measures quantitatively the amount of visceral and peripheral fat, we can measure the muscle type, et cetera. so that green is the fat that you want to get rid of that's associated with disease and we can give you these nice quantitative numbers if you really wanted to know whether your left leg weighed more than your right leg, for example, and what your different body parts contribute to it as well as the skeletal and joint condition. one of the biggest problems we have and it's quite surprising

to me it is males by almost a two to one ratio over females want to go through the health nucle nucleus. so me this is very straightforward, knowledge is power, if we find something, for example, these tumors, they're easily removable and people are cured, but women seem to be afraid to get the answers, so maybe some of you have the answers for this of how to convince them to go through, but it's for the same reason they don't want to go see their physicians, either. our age range is quite broad from relatively young to as old as 99. some people still want to live longer no matter how old they are and remarkably healthy individuals. our big challenge is trying to put all this data together. we're trying to take these new feen owe types and see if we can match it to changes in the genome using machine learning. some are obvious.

we see a lot of poly cystic kidney and liver disease. we're finding -- so we have now had five individuals with greatly distended aer tas and we found a gene duplication in one gene that seems to correlate with this. but you can still see from this chart we have a long way to go between the straight single gene disorders, the gwas which looks across the genome, there is still a pretty discordance with what the phenotype findings are. so we have a long way to go to make the genome predictive at the level that we want it to be. out of the first 209 people here is a partial list of the kind of things that we've discovered. essentially all of these have been actionable and treatable. there was only one case of very

deleterious white matter changes in the brain that probably were irreversible, even by proving the cardiovascular system there was some improvement in cognition with that person. these are all people who by any other definition were healthy. we're using a 12th century definition of health. if you don't appear to have symptoms and you feel okay, even by the u.s. healthcare system you are a healthy person. this data says that 40% of you are not. the data i showed you on the death rate prematurely from heart disease and cancer says you're not and we're up to about 1.5 million new cases of cancer diagnosed each year. those people just didn't come down with cancer the night before.

some of them have had it for weeks, some for months, some for years. if we can detect it earlier we can simply remove t we're using machine learning so i just want to show you a few things with what we do with machine learning because it's getting exciting and it hopefully will show you the potential as these databases get bigger and bigger we can make associations with any clinical findings in the genome. we started by wanting to predict a lot of things about people including eye color, hair color and face. we've found that, in fact, we're better at predicting people's eye color than they were at defining it and we use spectral imaging to get a precise color and it turns out people's eye color varies by about 14% from eye to eye so most people are unaware of that. so we can predict your eye color pretty well. getting quantitative skin color

is complicated because some people go out in the sun, some people use a lot of makeup, there's just a lot of different things with t but the coronations now are getting pretty good with that. so we can predict age, we can predict all these different features. so we put some of these together in the genome report that you get where we predict your height, your weight, your bmi, your eye color and your hair color. on that show her genome predicted a weight of 166 pounds, she used an extreme on scent at me when i pointed that out. i said, look, you just haven't achieved your genome potential, some of us have exceeded or genome potential. but we can actually now also predict other things. men and women lose chromosomes as they age, we lose -- men lose

their y chromosome, women lose their x chromosomes, we can quantitatively from the sequence measure telomere length and changes associated with change that are quantitative. we can measure from the met an loan there are things that do correlate well with changes in age and we set out to see if we could on top of that all that measure what you look like just from your as, cs, gs and ts. so we did a clinical study, took 1,000 videos, made 3-d images of their faces, sequenced their genomes and did a lot of other components. we are also trying to predict voice. just from a digital voice print whether over the telephone or any other things we can pretty accurately determine the sex, the age and the height of the person. the height surprised us in these

correlations but it somewhat correlates with your overall volume. so donald trump would have never been able to fool people with these simple tests trying to be his own press agent a few years back. so we take these 3-d images, we smooth them a little bit because of the 3-d photographs are somewhat harsh and we've taken these into our machine learning al grit i'm looking at thousands of bits across the genome. here is our current version of the face prediction that seems to match relatively well the 3-d photo. so this is just the genetic code as, cs, gs and ts. we don't put in the actual eye color that's predicted for these, it's just graphically difficult to get it right. here is another case of a male, the 3-d photo and here is the

genome prediction. here is an african-american male, because ethnicity such as a key part of these predictions it actually works extremely well and here is his 3-d prediction. so we can combine all this data of your height, your weight, your eye color, your hair color, an p photo of you that the photo on its own people can relatively identify one out of ten, but we also measure and know your blood type, your exact hla type. so males just with your y chromosome can usually be linked on the internet to a surname very quickly. so the point of all this is if you think -- and as the government and others will try to tell you your genome can be deidentified. we can identify you from your

genome. so be careful where you place it. [ laughter ] >> and if you're part of a study and told that you can be deidentified in that study, it's truly not possible. so we treat people's data highly securely, nobody can run the algorithms on anybody in our database to try to determine their identity and i think that's a key issue. so we're combining all these things, they are all improving with machine learning, but think about the same thing with all the different symptoms and measurements that we get for disease off the mri, for example, off the mri we get the exact diameter of people's spinal column and some people have a narrowing that's genetic. so we can predict in the future

those who much more likely to have lower back pain simply from those markers associated with this narrowing in the spinal cord. so at the earliest stages it's just getting exciting. we return the results to people on an ipad so you don't have to carry around a couple thousand pages of paper and we make a 3-d avatar out of each person with about a 200 camera system. it's the same kind of avatar they use in the movies so in the future they will be animated and help you walk through your own data. so if any of you are interested in learning more, you can go to human longevity.com, health nucleus.com or that's my e-mail address if you want to make an appointment. so thank you very much. [ applause ]make an appointment. so thank you very much. [ applause ] into thank you. thank you. thank you, craig. thank you very much.

thank you. >> thank you so much, craig. for your amazing insight and captivating look into the future, we wish you the best of luck. now i'd like to bring to the stage three other esteemed healthcare leaders. first we have tom daschle founder and chief executive officer of the daschle group. few people have such a profound understanding of the issues animating the current healthcare debate as tom. as senator majority leader tom established himself as a leading expert on national healthcare policy. he has remained deeply involved in the debate since leaving the senate and heads the daschle group while serving on influential policy bodies. tom also co-authored the book getting it done, how obama and congress finally broke the stalemate to make way for healthcare reform. he continues to be a key voice in healthcare in america. please give a big hand for tom daschle. [ applause ]

>> also with us today is redonda miller. in may redonda became the 11th president of the johns hopkins hospital. she previously served as senior vice president of medical affairs for the johns hopkins health system as well as a professor and vice chair for clinical operations in the department of medicine. redonda has made medical education and women's health a major focus of her academic and clinical career. she chairs the maryland hospital associations council on clinical and quality issues and is a fellow of the american college of physicians. as she governs she plans to continue caring for patients as she said in a recent interview seeing patients will keep me grounded and help me remember why i'm here. please join me in welcoming redonda miller. [ applause ] next